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Uses

Edema

Management of edema associated with CHF, hepatic cirrhosis, and renal disease (e.g., nephrotic syndrome).

Considered a diuretic of choice for most patients with CHF.

IV management of acute pulmonary edema (in combination with oxygen and a cardiac glycoside).

Hypertension

Management of hypertension (alone or in combination with other classes of antihypertensive agents).

One of several preferred initial therapies in hypertensive patients with CHF or renal disease.

Can be used as monotherapy for initial management of uncomplicated hypertension; however, thiazide diuretics are preferred by JNC 7.

Dosage and Administration

General

Edema

• Careful etiologic diagnosis should precede the use of any diuretic.
• Hospitalization of the patient during initiation of therapy is advisable, especially for patients with hepatic cirrhosis and ascites or chronic renal failure.
• Most experts state that all patients with symptomatic CHF who have evidence for, or a prior history of, fluid retention generally should receive diuretic therapy in conjunction with moderate sodium restriction (≤3 g of sodium daily), an ACE inhibitor, and usually a β-blocker, with or without a cardiac glycoside.
• In prolonged diuretic therapy, intermittent use of the drug (e.g., on 2–4 consecutive days each week) may be advisable.

Hypertension

• Monitor BP carefully, especially during initial therapy.
• If added to regimen of a patient receiving another antihypertensive agent, reduce dosage of preexisting therapy by at least 50% initially to avoid severe hypotension; additional dosage adjustment may be required.

Administration

Administer orally, IV, or IM.

Oral Administration

Administer orally once (preferably in the morning) or twice daily .

For ease of administration and maximum dosage flexibility in children, consider use of oral solution preparation.

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

IV administration may be used in emergency clinical circumstances when a rapid onset of diuresis is desired, or in patients unable to take oral medication or those with impaired GI absorption; replace with oral therapy as soon as possible.

Consider the potential risks, when using large parenteral doses; monitor patient closely.

Dilution

For IV infusion, dilute in 5% dextrose, 0.9% sodium chloride, or lactated Ringer’s injection and adjust pH to >5.5.

Whenever possible, use vials instead of ampuls to prepare large doses to prevent large quantities of glass particles from entering the solutions. If ampuls must be used, consider filtering through a sterile membrane filter before use to remove any particles that may be present.

Rate of Administration

For direct IV injection, administer slowly over a period of 1–2 minutes.

If high-dose parenteral furosemide therapy is necessary, the manufacturer recommends that the drug be administered as a controlled infusion at a rate not exceeding 4 mg/minute in adults.

Dosage

Individualize dosage according to patient’s requirements and response; titrate dosage to gain maximum therapeutic effect while using the lowest possible effective dosage. (See Boxed Warning.)

Pediatric Patients

Edema

Oral

2 mg/kg administered as a single dose. If necessary, increase in increments of 1 or 2 mg/kg every 6–8 hours to a maximum of 6 mg/kg. Generally not necessary to exceed individual doses of 4 mg/kg or a dosing frequency of once or twice daily. Use minimum effective dosage for maintenance therapy.

IV or IM

1 mg/kg administered as a single IM or IV injection. If necessary for resistant forms of edema, the initial dose may be increased by 1 mg/kg no more often than every 2 hours until the desired effect has been obtained or up to a maximum dosage of 6 mg/kg. Adequate response usually is obtained with individual parenteral doses of 1 mg/kg.

Acute Pulmonary Edema

IV or IM

1 mg/kg administered as a single IM or IV injection. If necessary for resistant forms of edema, the initial dose may be increased by 1 mg/kg no more often than every 2 hours until the desired effect has been obtained or up to a maximum dosage of 6 mg/kg. Adequate response generally obtained with 1 mg/kg.

Hypertension

Oral

Initially, 0.5–2 mg/kg given once or twice daily. Increase as necessary up to a maximum of 6 mg/kg daily.†

Adults

Edema

Oral

20–80 mg given as a single dose, preferably in the morning. If needed, repeat same dose 6–8 hours later or increase dose by 20- to 40-mg increments and give no sooner than 6–8 hours after last dose until desired diuretic response (including weight loss) is obtained. May titrate carefully up to 600 mg daily in severe cases.

The effective dose may be given once or twice daily thereafter, or, in some cases, by intermittent administration on 2–4 consecutive days each week. Dosage may be reduced for maintenance therapy.

IV or IM

20–40 mg given as a single IM or IV injection. If needed, repeat same dose 2 hours later or increase dose by 20-mg increments and give no sooner than every 2 hours until the desired diuretic response is obtained. Effective dosages may then be given once or twice daily.

Acute Pulmonary Edema

IV

40 mg given as a single IV injection. If needed, an 80-mg dose may be given 1 hour after the initial dose.

Hypertension

Oral

40 mg twice daily. If desired BP not attained, consider adding other antihypertensive agents.

Usual dosage recommended by JNC 7: 10–40 mg twice daily.

Prescribing Limits

Pediatric Patients

Edema

Oral

Maximum of 6 mg/kg.

IV or IM

Maximum of 6 mg/kg in infants and children; do not exceed 1 mg/kg daily in premature infants.

Hypertension

Oral

Maximum 6 mg/kg daily.†

Adults

Edema

Oral

Maximum of 600 mg daily.

Special Populations

Dosage in Renal Impairment

Higher doses may be required for patients with acute or chronic renal failure.

Hypertension

Higher doses may be required for patients with acute or chronic renal failure.

Oral

Use of ≥3 antihypertensive agents usually is required to achieve a target BP <130/80 mm Hg.